Summary

The tibial shaft is the most commonly fractured long bone in the body. Due to its subcutaneous anatomical position (the "shin bone"), it has the safest soft tissue envelope but the highest rate of open fractures (25%). Management is dictated by the energy of injury and the state of the soft tissues. Intramedullary (IM) Nailing is the gold standard for most unstable adult fractures (SPRINT Trial supports Reamed nails). Compartment Syndrome is a devastating complication that must be ruled out in every case. Open fractures require urgent antibiotic prophylaxis and debridement (BOAST Guidelines / Gustilo-Anderson). [1,2,3]

Key Facts

• Most Common Long Bone Fracture: ~40% of long bone fractures.
• Open Fractures: The tibia is the #1 site for open fractures. The "Rule of 3s" applies: 1/3 of the tibia is subcutaneous.
• Compartment Syndrome: The anterior compartment is the most commonly affected compartment in the body. Pain out of proportion to injury and Pain on Passive Stretch are the only reliable early signs. Pulses remain present until it is too late.

Clinical Pearls

"Reamed is Better": The SPRINT trial conclusively showed that Reamed IM nails have lower rates of non-union and implant failure compared to Unreamed nails for closed fractures.

"The 6 Hour Rule": Historically, open fractures needed debridement within 6 hours. Modern data suggests <24 hours is safe IF antibiotics are given immediately (within 1-3 hours of injury).

"Antibiotics Matter": For Gustilo I/II, give Cephalosporin. For Gustilo III (high energy/soil), add Gentamicin + Metronidazole (or follow local trauma protocol like Co-amoxiclav).

                 TIBIAL SHAFT FRACTURE
                        ↓
             OPEN OR CLOSED? (Check Skin)
            ┌───────────┴────────────┐
          OPEN                     CLOSED
            ↓                        ↓
   **MANDATORY STEPS**        COMPARTMENT SYNDROME?
   - IV Abx (ASAP)           (Pain > Injury)
   - Tetanus                ┌──────┴──────┐
   - Photo & Cover         YES           NO
   - Plastic Consult        ↓             ↓
            ↓           FASCIOTOMY    STABLE?
     URGENT SURGERY                   ┌───┴───┐
     (Debride + Fix)                YES      NO
                                     ↓        ↓
                                   CAST      IM NAIL
                                (Sarmiento) (Standard)

Indications

• Closed fracture.
• Low energy.
• Minimal displacement (<50% translation, <5° angulation).
• Patient preference/comorbidities.

Protocol

1. Above Knee Cast: With knee flexed 10-20° for 4-6 weeks (controls rotation).
2. Sarmiento Brace (Patella Tendon Bearing Cast): At 4-6 weeks. Allows knee/ankle motion while compressing the calf (hydrostatic pressure) to stabilize the fracture.
3. Union: Average 16-20 weeks. (Slow).

1. Intramedullary (IM) Nailing (Gold Standard)

• Indications: Unstable closed fractures. Gustilo I-IIIA open fractures.
• Technique:
  • Reamed: Passing a reamer opens the canal, stimulates blood flow (autograft), and allows a larger nail. Superior to unreamed.
  • Locking Screws: Proximally and distally to prevent rotation and shortening.
• Advantage: Load-sharing device. Allows early weight bearing (Immediate).

2. External Fixation

• Indications:
  • Severe soft tissue injury (Tscherne 3 / Gustilo IIIB).
  • Damage Control (Polytrauma).
• Goal: Bridge the zone of injury. Restore length. Allow soft tissue access.
• Risks: Pin site infection. Malunion.

3. Plating (ORIF)

• Indications: Distal or Proximal metaphyseal fractures where a nail doesn't fit well.
• Risks: Requires large incision (stripping periosteum). Higher infection rate than nailing.

SPRINT Trial (2008)

• Study of Reamed vs Unreamed IM Nails for closed tibial fractures.
• Result: Reamed nails had significantly fewer bone graft surgeries and led to faster union.
• Lesson: Always ream closed fractures.

LEAP Study (Lower Extremity Assessment Project)

• Analyzed salvage vs amputation for severe open fractures (IIIB/C).
• Result: Sickness Impact Profile (SIP) scores were equivalent at 2 years whether the leg was saved or amputated. Saving the leg is not always "better" functionally if it is painful and insensate.

What is the injury?

You have broken the main bone in your lower leg (shin bone).

Do I need surgery?

If the bone has moved out of place (which it usually does), a cast will not hold it straight enough. We usually put a metal rod (Nail) down the hollow center of the bone. This acts like an internal splint.

What if the bone came through the skin?

This is an "Open Fracture". It is an emergency because bacteria can get into the bone. We need to clean it immediately in the operating room and give you strong antibiotics to prevent deep infection.

Recovery

With the metal rod, you can usually walk on the leg immediately (as pain allows). It typically takes 3-6 months for the bone to heal completely.

Q1: What are the 4 compartments of the leg? A: Anterior, Lateral, Superficial Posterior, Deep Posterior.

Q2: Describe the Gustilo-Anderson Classification for Type III fractures. A: IIIA: Adequate soft tissue coverage (despite high energy/comminution). IIIB: Periosteal stripping / Bone exposure requiring Flap coverage. IIIC: Vascular injury requiring repair (regardless of soft tissue state).

Q3: What did the SPRINT trial show? A: That reamed intramedullary nailing is superior to unreamed nailing for closed tibial fractures (lower rate of re-operation and non-union).

Q4: What is the most common sensory deficit in Compartment Syndrome of the leg? A: Numbness in the first dorsal web space (Deep Peroneal Nerve - Anterior Compartment).

(End of Topic)